Students Name: Emily Roberts, Kelsey Saralampi, Christian Chapin, Shelly Peck, Zoe Parris Course Name: Role Integration Date:
Step 1: List your PICO question:
In adults receiving abdominal surgery, what is the effect of chest physiotherapy on the incidence of respiratory infections postoperatively compared with no chest physiotherapy?
Step 2: Evidence Critique
Citation (APA)
Purpose
Ethical Principles
Design
Level of Evidence*
Sample
Measurement & Data Analysis-
Results/ Conclusions
Limitations
Westwood, K., Griffin, M., Roberts, K., Williams, M., Yoong, K., & Digger, T. (2007, December 5). Incentive spirometry decreases respiratory complications following major abdominal surgery. Surgeon (Edinburgh University Press), 5(6), 339-342.
To see if adding incentive spirometry to a intensive postoperative regimen following major abdominal surgery decreases the incidence of respiratory complications
There were no changes in consultant anaesthetic, consultant surgical, nursing or physiotherapy staff during the study period. No protocols were introduced or changed that would affect patient care, length of stay or physiotherapy contacts with patients
Non-randomized
study, prospective
observational
study
Level 2
263 patients
at an average
age of 67 all on the surgical
high dependency
unit
Length of stay on SHDU and in hospital to discharge, post-operative pulmonary complication (PPCs), time spent by physiotherapy staff with each patient and on-call physiotherapy contacts. PPCs were defined as the presence of clinical features consistent with collapse or consolidation, plus an otherwise unexplained temperature above 38°C, and either positive findings on chest radiography or evidence of infection from sputum microbiology.
Demonstrated a decreased incidence of PPC when IS is added to an intensive program of post-operative physiotherapy. Associated with this is a shorter length of stay on SHDU, less physiotherapy time with each patient and fewer on-call physiotherapy contacts.
Other objective measurements, such as peak expiratory flow, FVC and FEV1, could have been employed to further investigate recovery of respiratory function in the two groups.
Dronkers, J., Veldman, A., Hoberg, E., C, & Van Meeteren, N. (2008). Prevention of pulmonary complications after upper abdominal surgery by preoperative intensive inspiratory muscle training: a randomized controlled pilot study. Clinical Rehabilitation, 22(2), 134-142.
To investigate the feasibility and effects of preoperative inspiratory muscle training on the incidence of atelectasis in patients at high risk of postoperative pulmonary complications scheduled for elective abdominal aortic aneurysm surgery.
Informed consent forms were signed by all patients and the protocol was approved by the medical ethics committee of the University Medical center Utrecht and of the Gelderse Vallei Hospital, the Netherlands
Single-blind randomized controlled pilot study
Level 1
Twenty high-risk patients undergoing elective abdominal aortic aneurysm surgery were randomly assigned to receive preoperative inspiratory muscle training or usual care
Effectiveness outcome variables were atelectasis, inspiratory muscle strength and vital capacity, and feasibility outcome variables were adverse effects and patient satisfaction with inspiratory muscle training
Preoperative inspiratory muscle training is well tolerated and appreciated and seems to reduce the incidence of atelectasis in patients scheduled for elective abdominal aortic aneurysm surgery.
Small number of patients
Lange, B., Flynn, S., Chang, C., Rizzo, A., & Bolas, M. (2011). Breathe: a game to motivate the adherence of breathing exercises. Journal Of Physical Therapy Education, 25(1), 30-35.
To develop a game using an incentive spirometry system that will help motivate patients to perform breathing exercises, provide a quantitative measurement for patient progression, and to monitor adherence to breathing interventions.
Nonrandomized control pilot study
Level 3
19 healthy participants were used the first round of testing. 6 therapists and 6 patients were used the second round of testing.
Six prototypes incentive spirometry device games were developed and then were
tested by users. Two of the six were further tested by physical therapists and
patients. The usability was assessed and comments were provided on the device,
system goals, game play, and any prospective improvements.
Integration video game technology into medical devices allows for better assessment and helps to collect objective data on patient adherence to breathing exercises and their lung functions compared to standard treatments. This trial provides a basis for developing other game related tools that can be used for rehabilitation.
Harbrecht, B., Delgado, E., Tuttle, R., Cohen-Melamed, M., Saul, M., & Valenta, C. (2009). Improved outcomes with routine respiratory therapist evaluation of non-intensive-care-unit surgery patients. Respiratory Care, 54(7), 861-867.
To determine if having a respiratory therapist direct evaluation and treatment for non-ICU surgery patients opposed to physician driven treatment would reduce the respiratory complications postoperatively and lead to improved outcomes.
Nonrandomized control pilot study
Level 3
2,230 patients admitted during control and 2,805 in the 8 months following intiation of the protocol.It was implemented
in the neurosurgery stepdown unit, the trauma/surgery step down unit and
general ward.
They used a standardized patient-assessment tool to identify the risk factors for pulmonary complications and to guide the frequency of treatments. The assessment included pulmonary history, surgical history, chest radiograph, respiratory patterns, breath sounds, cough, mental status, activity level, laboratory data, and pulse-oximetry readings. A score of 0, being normal, to 4, being abnormal. They collected data on demographics, admitting service , number and type of treatments, stay and mortality. Hospital costs were compared from before and during the trial based on the hospital’s financial database.
The respiratory therapist guided evaluate and treat protocol lead to an increase in amount of patients on respiratory treatments with fewer treatments per each patient. These patients had shorter ICU and hospital stays. This lowered total hospital costs compared to physician directed respiratory therapy. Routine respiratory therapy evaluations lead to improved outcomes.
Comorbidities that were not identified before the trial may have impacted the results. It was only implemented in select units which many have limited the number of patients and the ability to identify differences between groups. Shorter stays in ICU occurred after implementation but can’t be directly proven to have caused the effect. The study didn’t measure other interventions, such as early ambulation, contributing effects.
Guimarães, M., El Dib, R., Smith, A., & Matos, D. (2009). Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database Of Systematic Reviews, (3), doi:http://dx.doi.org.bsuproxy.mnpals.net/10.1002/14651858.CD006058.pub2
To examine the results of patients using the incentive spirometer as opposed to no intervention or therapies regarding post operative respiratory complications
Informed consent was given in order to participate in this study. Participants were all over the age of 18.
Experimental
Randomized control trials
Level 2
Random Sample taken from three comparisons of interventions with a total number of participants of 1,260 people
Statistical analysis in the form of risk ratios (RR)
The study concludes with no measurable difference or evidence in terms of using incentive spirometry in preventing post operative respiratory complications following abdomnal surgery.
There were not any standardized outcomes or measures for compliance with various therapies
Pasquina, P., Tramèr, M. R., Granier, J., & Walder, B. (2006). Respiratory Physiotherapy To Prevent Pulmonary Complications After Abdominal Surgery. Chest, 130(6), 1887-1899. doi:10.1378/chest.130.6.1887
To examine the benefits of different pulmonary therapies to prevent pulmonary complications following abdominal surgery
Experimental
Clinical trials; Case Studies
Level 4
Analyzed 35 random trials with a total of 4145 adult patients
Statistical analysis and risk differentials (RD)
Only a few of the trials that were reviewed were shown to prove that chest physiotherapies were preventing respiratory complications following surgery.
Limitations that were noted included the validity and strengths of the original studies, problems with reporting and variation of trial sizes
Orman, J., & Westerdahl, E. (2010). Chest physiotherapy with positive expiratory pressure breathing after abdominal and thoracic surgery: a systematic review. Acta Anaesthesiologica Scandinavica, 54(3), 261-267. doi:http://dx.doi.org.bsuproxy.mnpals.net/10.1111/j.1399-6576.2009.02143.x
To determine the effect of PEP (positive expiratory pressure)breathing after an open upper abdominal or thoracic surgery
Literature search of randomized controlled trials reviewed by two independent observers
Level 3, correlation/
case studies
Randomized controlled trials
Literature review of five databases
Only one of the trials showed any positive effects of PEP compared to other breathing techinques, scarce evidence that PEP is better than any other physiotherapy breathing techniques.
Only able to study previously documented research and not able to implement their own ideas.
Weindler, J., & Kiefer, R. (2001). The efficacy of postoperative incentive spirometry is influenced by the device-specific imposed work of breathing. Chest, 119(6), 1858-1864.
To identify the success of incentive spirometers in reducing PPCs compared to other chest physiotherapy interventions.
Statistical analysis
Level 2
30 male patients, post upper abdominal surgery
Statistical analysis
After comparing incentive spirometry and chest physiotherapy, for the prevention of pulmonary complications after upper abdominal surgery, they were found to be equivalent. For monitored incentive spirometry, the authors reported a significantly lower incidence of PPCs and significant shorter hospital stays.
Wentzell, J.D. (2010). COPD and post-operative respiratory complications: a case study. Canadian Journal Of Respiratory Therapy, 46(4), 25-32.
Track the management of a mechanically ventilated post-operative patient with chronic obstructive pulmonary disease (COPD)
Signed consent for patient health history
Case study
Level 3
55 year old male patient admitted to the emergency department
Case study, labs evaluation
Post-operative respiratory complications are as significant a
cause of morbidity and mortality and increased length of stay
in the perioperative patient as post-op cardiac complications
(1) though the importance of these respiratory complications
may be clinically undervalued (2). With the increasing age
of the patient population and increasing number of patients
with COPD, a larger number of patients will fall into this atrisk
category (2). It is vital that RRTs be knowledgeable about
the risk factors for post-op respiratory complications; rapidly
identify patients who may be at risk for complications; and
implement management strategies when these complications do occur.
Limited case study information for only one patient and unable to compare to the results of others
Denehy, L., Carroll, S., Ntoumenopoulos, G., & Jenkins, S. (2001). A randomized controlled trial comparing periodic mask CPAP with physiotherapy after abdominal surgery.Physiotherapy Research International, 6(4), 236-250.
To compare the effects of two dosages of Periodic continuous positive airway pressure (PCPAP) and traditional physiotherapy upon functional residual capacity, vital capacity, oxyhemoglobin
saturation, incidence of post operative pulmonary complications and length of stay with a control group receiving traditional physiotherapy only
Approved by the Human Research Ethics Committee of the hospital and written, informed consent was obtained from each subject
Randomized controlled trial
Level 1
58 adult subjects admitted for elective upper abdominal surgery
Functional residual capacity, vital capacity, oxyhemoglobin
saturation were all measured
There were no significant differences in any variables between the groups showing that traditional physiotherapy is just as effective as PCPAP
Small number of subjects, day of ambulation was not documented
Step 3: Appraisal & Synthesis of the Evidence:
Overall Quality of Evidence
Predictability / Probability
Overall Accuracy
Financial Issues
Clinical Significance
Actions Based on Evidence Appraisal
Other comments / Gaps in Literature
Is there enough quality evidence to support your change? Is there a gap in the evidence?
How generalizable is this information?
Could it be used to predict other results? Could it be applied to other areas?
Accuracy of results
Is there a cost associated in any way?
What are the practical aspects? Is there a clinical significance to this information? This might be different than statistical significance.
Statement of justification of your proposed practice change
Anything else you feel you need to state about your project.
(Fictional example; delete the text from this row when you complete your worksheet)
The research reviewed showed 75% of the evidence (research) in the top 3 levels as per the Pyramid of evidence (Schmidt & Brown). Results were found in both qualitative and quantitative studies.
The studies were completed at large institutions of healthcare and education. The average N was greater than 300. Several of the studies used this concept in a new area demonstrating the transferability of some of the studies.
Showed statistical significance (give examples)
There will be minimal cost to the healthcare facility. However as the proposed change is a mandatory in-service salaries and patient coverage will have to be addressed.
Estimate salary cost – 5 RNs for 1 hours = $130.00.
This is a direct patient care practice change. It has the potential to shorten patient in-hospital days and therefore control costs but maintain patient satisfaction.
The overall results show clinical significance.
The proposed practice change is to provide home care patient education through the development of a take home discharge DVD.
The costs need to be more fully explored.
Step 4: Integrate the evidence with your own clinical expertise, patient preference and local context
Step 5: How would you evaluate if the outcome was achieved? What other factors related to a change process would you want to evaluate?
Course Name: Role Integration
Date:
Step 1: List your PICO question:
In adults receiving abdominal surgery, what is the effect of chest physiotherapy on the incidence of respiratory infections postoperatively compared with no chest physiotherapy?
Step 2: Evidence Critique
Conclusions
study, prospective
observational
study
at an average
age of 67 all on the surgical
high dependency
unit
tested by users. Two of the six were further tested by physical therapists and
patients. The usability was assessed and comments were provided on the device,
system goals, game play, and any prospective improvements.
in the neurosurgery stepdown unit, the trauma/surgery step down unit and
general ward.
Randomized control trials
Clinical trials; Case Studies
case studies
of a mechanically ventilated post-operative patient with
chronic obstructive pulmonary disease (COPD)
cause of morbidity and mortality and increased length of stay
in the perioperative patient as post-op cardiac complications
(1) though the importance of these respiratory complications
may be clinically undervalued (2). With the increasing age
of the patient population and increasing number of patients
with COPD, a larger number of patients will fall into this atrisk
category (2). It is vital that RRTs be knowledgeable about
the risk factors for post-op respiratory complications; rapidly
identify patients who may be at risk for complications; and
implement management strategies when these complications
do occur.
saturation, incidence of post operative pulmonary complications and length of stay with a control group receiving traditional physiotherapy only
saturation were all measured
Step 3: Appraisal & Synthesis of the Evidence:
Could it be used to predict other results? Could it be applied to other areas?
The research reviewed showed 75% of the evidence (research) in the top 3 levels as per the Pyramid of evidence (Schmidt & Brown). Results were found in both qualitative and quantitative studies.
Estimate salary cost – 5 RNs for 1 hours = $130.00.
The overall results show clinical significance.
Step 4: Integrate the evidence with your own clinical expertise, patient preference and local context
Step 5: How would you evaluate if the outcome was achieved? What other factors related to a change process would you want to evaluate?